Claims Analyst

Job Summary/Purpose:

Review and accurately enter claims for participants according to state and federal regulations and BRI Company and departmental policies and procedures.

Essential Job Duties and Responsibilities:

• Review claims for accuracy, ensuring all form fields are filled out completely.
• Determine eligibility of each claim per appropriate Section 105, Section 125 and Section 132 regulations and company policy.
• Accurately enter all claim data into claims entry program including, but not limited to, transaction code, service dates, received date, requested amount, denial code and amount, and address changes. Assist in ensuring that all claims are entered no later than five business days after claim received date.
• Create manual denial letters as needed for claims that cannot be reimbursed because they are incomplete and\or are ineligible per IRS regulations. Ensure that denial letters are created no later than 30 business days after claim received date and mailed to participants the following business day.
• Monitor and track all claims assigned in the document management system, processing oldest claims first. Escalate claims appropriately to leadership.
• Follow procedures written for handling special claims instances when processing claims in the document management system and the claims entry program. Ask questions when not sure.
• If assigned debit card follow-up, accurately enter debit card substantiation follow-up and unsuspended cards in the debit card administration software. Enter cardholder repayments and offset claims into administrative software. Assist in ensuring that this process is completed no later than five business days after follow-up received date.
• If assigned debit card follow-up, on a daily basis, send leadership the number of claims reviewed and processed, along with the number of substitute and repay claims processed to assist leadership in monitoring and tracking staff performance and progress.
• Perform a variety of miscellaneous administrative and job-related duties as requested to support operations and or achieve business goals and objectives including, but not limited to, audits, mailing, and ensuring timely responses to a variety of routine inquiries.
• Maintain knowledge of current state and federal laws and regulations affecting employee benefit claim administration including, but not limited to, Section 105, Section 125 and Section 132, ERISA, HIPAA, FMLA, HSA and COBRA regulations.
• Additional duties as assigned.

Accountabilities:

• Contribute to the overall success of the company by performing all assigned duties in a professional, timely, and accurate manner in accordance with established company procedures.
• Abide by BRI’s Five Guiding Principles of Dedicated Service, Innovative Solutions, Expertise, Integrity, and Teamwork.
• Follow BRI standard operating procedures for your department regarding administration of employee benefit plans.
• Act as a team player and work cooperatively with team members.
• Ensure compliance with regulations and company policies regarding security of Protected Health Information (PHI) and Personally Identifiable Information (PII).
• Demonstrate the integrity and discretion necessary to safeguard confidential data handled or obtained in the normal performance of job duties at all times.
• Inform supervisor, in a timely manner, of any issue that would impact the integrity of the claim review, entry or denial process and\or the claims department schedule.

Education and Experience:

• High school diploma or equivalent required; Associate’s degree preferred.
• One to three years experience in claim review, claim entry (or other data entry), medical billing, insurance, or health service experience preferred.
• Experience with word processing, electronic spreadsheets and email required.

Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities

The contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor’s legal duty to furnish information. 41 CFR 60-1.35(c)